Comprehensive Guide to Tracheostomy

TRACHEOSTOMY

Tracheostomy is an operative procedure which consists of making an incision in front of the neck and opening a direct airway through an incision in the anterior trachea through which tracheostomy tube is inserted which allows the person to breathe directly bypassing the nose, mouth and voice box.

INDICATIONS

1. Prolonged ventilatory support
a) adults- 7 – 10 days
b) Pediatric- 4 weeks
c) Neonates- 3 months (or earlier if the treating doctor feels that the
patients conditon requires prolonged ventilation)

2. Bronchial toilet
3.To bypass upper airway obstruction
4.As an adjunct to major head and neck surgeries

PROCEDURE

Tracheostomy is done under general or local anaesthesia. 2% xylocaine with adrenaline infiltration is done at the site of the incision. Neck is hyperextended so that trachea comes forward. Skin incision made(horizontal or vertical), subcutaneous tissue dissected out, strap muscles retracted laterally, thyroid isthmus retracted upwards/ divided and transfixed, pretracheal fascia dissected out. Once the tracheal cartilage is visualised, inject plain topical 4% lidocaine into the tracheal lumen or to administer additional IV anesthetic agents to decrease cough upon manipulation and entry into the trachea. After informing anesthetist, a cut is made and a small part of tracheal cartilage is removed (ideally between 2 nd and 4th tracheal rings). after checking the cuff, a tracheostomy tube is placed. The incision should be closed loosely and the tracheostomy tube secured in position with tapes, sutures or both.

Alternatively, and preferably (HH) an anteriorly-based flap (Bjork flap) may be created by incising between the tracheal rings (ideally between 2nd and 3rd – with decision re: location based on anatomic constraints) and then making parallel vertical cuts laterally through the second ring. The free end of the second ring is then secured to the dermis of the lower skin flap with 3- 0 vicryl sutures.

In children, a vertical incision is made in the midline. Retraction sutures are then placed on either side of the incision with 4-0 prolene sutures. These should be labeled "right" and "left" and taped to the patient's chest at the conclusion of the procedure. Removal of any cartilage should be avoided in children.

TRACHEOSTOMY TUBE TYPES

  • Cuffed/ Uncuffed
  • Fenestrated/ non- fenestrated/ variable length
  • Single lumen/ double lumen
  • Metallic/ non-metallic

TRACHEOSTOMY CARE TEAM

  • Consultant in ENT/ Laryngology
  • Tracheostomy care nurse
  • Respitaory therapist

DUTIES OF A CONSULTANT

  • To take decisions regarding tube change,
    decannulation, swallowing assessment,
    rehabilitation
  • To ensure appropriate management in case of
    complications
  • To anticipate, diagnose and plan treatment of
    conditions like subglottic edema, suprastomal
    granulation, suprastomal collapse
  • To educate the caregiver about the tracheostomy
    care before discharge

DUTIES OF TRACHEOSTOMY CARE NURSE

  • Should be able to notify any complications
    regarding tracheostomy and communicate the
    same with the team members
  • To carry out daily tracheostomy care
  • To educate the nursing staffs taking care of the
    patient regarding tracheostomy care
  • To make sure the availablity of an emergency
    tray containing all requires items along with a
    working suction unit and oxygen supply at the
    bedside

DUTIES OF A RESPIRATORY THERAPIST

  • To make sure the ventilatory requirement and
    settings are optimized as per the needs of the
    patient
  • To give chest physiotherapy
  • To assist in daily tracheostomy care

CARE OF NEW TRACHEOSTOMY

  • Pre op and immediate post op chest XRAY to rule out complications like pneumothorax and subcutaneous emphysema
  • Tapes should be secured properly. Ties should be checked before moving the patient
  • Cuff inflated and cuff pressure maintained at 20-25cm of water
  • For children stay sutures taped to chest till first tube change and maturation sutures to be done
  • For initial 12-24 hrs, hourly based suction ma be needed. Then suctioning needd to be done `as required basis’. Saline/ acetyl cysteine nebulisation if secretions are thick.
  • Humidification to be given through heat moisture exchanger filter/ Saline soaked gauze
  • Watch for complications
  1. Pneumothorax
  2. Bleeding
  3. Subcutaneous emphysema
  4. Wound infection
  • Feeding- if there is no feeding issues, feeding
    can be started after 3- 4 hours.

CARE OF TRACHEOSTOMY IN WARD/
ROOM ( around 7 days post operatively)

  • First change of tracheostomy tube (to be
    performed by an experienced clinician
    preferably an ENT surgeon)
  • First tube change in obese patients and difficult
    airway cases like acromegaly, Pierre Robin
    Sequence, Severe kyphocoliosis. S/P OMFS
    surgeries for multiple facial trauma should be
    done in OT or in an ICU facility

Equipments to be available in bedside

  • Suction catheters and suction equipment
  • Clean gauze
  • Personal protective equipment – protective eyewear, gloves, face mask and apron
  • Saline bottle(100ml)
  • 2 ml syringe and ampule 0.9 percent sodium chloride for cleaning and irrigation
  • Oxygen
  • Pulsoximetric monitoring SOS
  • Tapes/ roll gauze to be used as tie
  • Rolled up towel or blanket for positioning

Emergency tracheostomy box should contain

  • A spare tracheostomy tube/ endotracheal tube (same size and one size smaller)
  • Xylocaine jelly
  • Round- ended scissors
  • Spare tracheostomy tapes

TRACHEOSTOMY TAPE CHANGE

  • It is a two person procedure
  • Perform a hand wash. Put on PPE
  • Ensure emergency equipment is readily available
  • Patient positioned with a rolled-up towel under shoulders
  • Assistant should hold the tube in position using their thumb and index finger
  • Tapes should be cut between the Knot and the flange and the old tapes removed
  • Stoma and the neck to be cleaned above, below the stomal opening, under each flange, always wipe away from the stomal edges and finally clean around the back of the neck
  • Thread the new tape through the flange on both sides. Tie the tapes using a bow (After removing neck extension-should be able to slip in one finger comfortably)

SUCTIONING

  • Suctioning should be done only when needed (except if the airway is new- i.e less than 7 days and before the first tube change )
  • Suction catheter should be double the size of the suction tube (eg. For a tracheostomy tube of size 6.0, use a suction catheter sized 12 F or smaller)
  • Suction should be applied only on withdrawal
  • Suction pressure should be less than 150 mmhg for adults and between 80- 100 for pediatric patients
  • Suctioning should be quick (less than 15 seconds)
  • The tip of the suction catheter should remain within the tracheostomy tube and not be passed further down
  • Suction catheter should be only touched at its proximal end (to minimise contamination)
  • Catheters can be re-used during the same episode of suctioning if the distal end is free from secretions
  • Acetyl cysteine nebulisation if secretions are thick prior to suctioning

CARE OF SITE- STOMA AND NECK

  • If the area around the stoma becomes red,
    swollen, inflamed, warm to touch or has a foul
    odour, or if the patient develops fever inform the
    primary consultant/ tracheostomy care team

HUMIDIFICATION

Without appropriate humidification, secretions can become increasingly thick leading to blockage of the tube. Hence artificial humidification is recommended and can be done in many ways

  • Humidified oxygen
  • Heat moisture exchanger of appropriate size (If heat moisture exchanger is not available, wet sterile gauze with sterile normal saline can be spread over the tracheostomy tube which should be changed as required )
  • Adequate systemic hydration of the
    patient

CARE OF INNER CANNULA

Never shift the patient to ward/ room or home
without inner cannula

PROCEDURE

  • Wash and sterilize both hands and wear sterile
    gloves
  • After fixing the flanges with one hand remove the inner cannula by either rotation or pulling out the outer ring depending on the type of the tube
  • Clean the secretions with roller gauze passed through the inner cannula or with a sterile brush
  • Wash with saline or sterile water/ use 3% hydrogen peroxide (half strength diluted in sterile water) if there are thick secretions
  • Allow it to dry
  • Reintroduce the inner cannula and make sure that it is locked properly

DECANNULATION PROTOCOL

CRITERIA:

  • The indication for which tracheostomy was done has been resolved
  • Patient should not be dependent on a ventilator
  • Patient’s mental status should be to the level of alert and responsive and should be able to manage their oral secretions without a risk of aspiration
  • Patient should be able to have effective cough and clean his/her tracheal secretions
  • Laryngoscopic examination- confirm airway patency/ rule out aspiration
  • Swallowing assessment if tracheostomy is done for a neurological cause (post CVA, Head injury) and for children

TEMPORARY DECANNULATION/ TRIAL DECANNULATION

  • Deflate the cuff (if its non- fenestrated tracheostomy tube)
  • Close the tracheostomy tube witbh a Decannulation plug
  • Monitoring SPO2 for 24 hrs, if tolerating well plan for permanent decanulation

PERMANENT DECANNULATION

  • The patient is placed supine (flat) on their bed, the tube is removed and the opening into neck is covered with sterile gauze and a tape is placed over the gauze
  • The patient is instructed to occlude the gauze with their finger tip every time they cough or speak so that air doesn’t leak
  • They should change the gauze and the tape atleast once a day until the hole is healed
  • Plan for sugical closure in a minority of patient (<10%), if there is persistence of Tracheocutaneous fistula.

REFERENCES
CLEVELAND CLINIC
Iowa
Scot 8 th
Association of phonosurgeons

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